If you've read the blog here at CanDo Kiddo for long, you know I advocate for limiting babies' time in what I call "Baby Holding Devices." This is a term I use to describe baby gear that supports infants in a semi-reclined (lounging back) position and restricts their freedom of movement as well as the ability to actively interact with their surroundings. If you're new to the CanDo Kiddo blog, What Every Parent Needs To Know is a great next step after this post.
While it is possible to raise a baby without any Baby Holding Devices (other than a car seat for transportation in the car), I recognize it's not realistic or desirable for most parents. Instead, I recommend that parents use baby gear in moderation and with high levels of awareness and intentionality.
Two crucial aspects of intentional use of baby gear:
- being aware of your baby's body posture while in Baby Holding Devices
- taking steps to support healthy positioning
Why Your Baby's Posture Matters
Babies grow and develop in the womb curled into the "fetal position" and squished into asymmetric body positions. Labor and delivery can result in minor muscle or skeletal trauma, resulting in asymmetric body positions. For these reasons and more, infants VERY frequently arrive into the world with some degree (often very subtle) of asymmetric body position. Some research indicates that over 70% of newborns have some degree of neck or head asymmetry. I often refer to these asymmetric positions as a baby's "preferred position" or "womb position."
Given adequate opportunities for active movement and interaction with their surroundings, most babies will stretch and strengthen out of these asymmetries. Occasionally more significant or persistent asymmetries will require short-term intervention (typically physical or occupational therapy) to stretch tight muscles and strengthen others.
The more time a baby spends in Baby Holding Devices, the less time they have to stretch and strengthen out of these very common, subtle asymmetries. Additionally, the semi-reclined position of Baby Holding Devices allows gravity to pull baby into his "preferred position" and supports baby comfortably there for extended periods of time.
So, two mechanisms are at play with Baby Holding Devices: reduced time to naturally stretch and strengthen out of asymmetries AND more time in asymmetric postures. These two mechanisms can contribute to more significant, prolonged postural asymmetries that can have long-term effects on motor development, sensory development and cognitive development.
Safe and Healthy Infant Positioning
Knowing what to look for is a big part of making sure your baby is in a safe and healthy position in baby gear. Here are 3 simple things to check for:
Midline Positioning of the Neck, Body and Hips
Looking straight at your baby's front, imagine a line running from the top of baby's head to the middle of her diaper. You want to help baby maintain a straight neck and spine at this midline or middle of her body.
Let's take a look at this sweet girl lounging happily. The imaginary line from her head to her diaper resembles a backwards letter C. Her head and hips are shifted to her right (toward the left side of her lounger), creating asymmetry of the neck and torso. Without physically evaluating her I can't be sure if this is a "preferred position" for her (i.e. if she already has underlying musclular or skeletal asymmetries) but too much time in this position will likely lead to shortened muscles on the right side of her body (your left when you're looking at her), which can then make it harder for her to use her right hand, to lift her head in Tummy Time, to turn to see objects on her right side, to turn toward sounds or touch sensations on her right side, to roll, to use both arms equally to assume the hands and knees position for crawling, to sit upright. You can start to see how everything is related, right?
Alternating Head Position
It can be really tough to control how your baby positions his head all night long while still following SIDS precautions (flat sleeping surface with no pillows or positioners). But during daytime hours, you have much more frequent opportunities to notice and change baby's head position. In baby gear, you want to encourage looking left, looking right and holding head in the middle or midline of the body.
Let's look at this little baby burrito. He is perfectly demonstrating how a head tilt from asymmetrical neck positioning can contribute to a flat spot on the head. His head is tilted to his right (the left side of his bouncy seat) and rotated to his left. This tilt and rotate position is VERY common with Torticollis (one-sided neck tightness). Again, without getting my hands on him I can't be sure if this is a "preferred position" for him or if he has Torticollis, but you can see how too much time in this position could easily lead to flattening on the back left side of his head, which is resting against the bouncy chair.
Chin Away From Chest and Shoulders
Manufacturers of baby wraps, slings and soft-structured carriers like the Boba or Ergo do a great job of conveying the importance of keeping baby's airway open when worn. But the makers of Baby Holding Devices like bouncy seats, car seat carriers and infant swings don't seem to be as vocal about this message.
The risk of a baby's head falling toward his chest or shoulder in a way that compromises his airway is one of the reasons why the American Academy of Pediatrics SIDS safety guidelines warn against babies sleeping in baby gear.
If your little one's positioning looks like this snoozing dude when baby is awake, the incline of that piece of gear is TOO steep for your baby's current neck strength and you should refrain from using that device at this time.
Tips for Positioning in Baby Gear
- When you put your baby in a Baby Holding Device, snap a quick photo with your phone (as if you need another reason to take a picture of your cutie!). Every few days, scroll through the photos to look at your baby's position. This will help you notice any preferred positions she's assuming across multiple pieces of baby gear so that you can proactively position her in different positions.
- Use rolled hand towels or receiving blankets alongside baby's body to help support her shoulders directly in line with her hips.
- If your baby has a preferred head position (tilt and/or rotation), use an infant head rest marketed for car seats in any Baby Holding Device to help support his head at midline for some of the time he spends in baby gear.
- Encourage alternating head position by moving baby gear around the room. If your infant swing is positioned so that the family dining table is on the left, your baby will typically look left each night while the family eats dinner. A simple change of the swing's position every few days will encourage baby to actively turn his head each direction.
*NOTE: Do not add any items for positioning your baby in his car seat during travel in a car, including the infant head rests marketed for car seats. These are NOT safe for use in a moving vehicle - read this post to learn why aftermarket products like this aren't safe in car seats. Instead, if you must leave your baby in the car seat carrier when you arrive at your destination, add positioners then to achieve healthy positioning when not in the car. Be sure to remove all positioners when you place baby back in the car for travel. Yes, even if she's asleep.
Other Tips for Safe and Healthy Use of Baby Gear:
Limit Time In Baby Gear
I recommend parents follow the rule of 2 and 15 for using baby gear in moderation:
- An average of no more than 2 hours a day in Baby Holding Devices (all devices combined, including car seat use in the car). Because this is an average, if one day involves more car time than usual or a fussy day requires more time in baby gear, just aim for less than 2 hours for the next few days.
- No more than 15 minutes at time in Baby Holding Devices without a position change and a check that baby couldn't be content on the floor for unrestricted play, being worn or held.
Don't Let Baby Sleep In Baby Gear
New parents are TERRIFIED of stomach sleeping because of SIDS. But very few are aware that sleeping in Baby Holding Devices is also a SIDS risk. The American Academy of Pediatrics recommends that sleeping babies be removed from baby gear as soon as is practical and placed on a flat, firm mattress without bedding, stuffed toys, crib bumpers, etc.
Educate Your Baby's Other Caregivers
Many parents aren't the only folks routinely watching their babies. Share this information with your baby's daycare, nanny, grandparents and other regular caregivers. Outline your expectations: "I'd like him to spend an hour or less in baby gear each day since he's in the car seat for an hour a day getting to and from daycare." "He likes to fall asleep in the swing. Please move him to the Pack 'n Play if he does." "I printed off a picture of the way she often sits in her bouncy seat and swing and a picture of how we use rolled blankets to help her sit more straight. Please help her avoid that crooked position."
Enlist The Help Of A Professional
If you notice significant asymmetries or preferred positions that aren't getting better, if your baby doesn't appear able to turn her head in each direction or if your little one is developing a flat spot, seek the help of a professional. Discuss your concerns with your child's primary care provider. Bring the photos you've taken to show how frequently you're seeing positional preferences.
"Let's wait and see," is a frequent, but NOT RESEARCH-BASED RESPONSE. The American Academy of Pediatrics has numerous clinical guidelines for physicians that highlight the importance of parent education and early referral for intervention to address Torticollis and Plagiocephaly. If your child's physician is unable or unwilling to walk you through repositioning strategies and/or stretching exercises, ask for a referral to a pediatric physical or occupational therapist with experience treating infants. You are your child's best advocate!
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